Department of Anesthesia, University of Alberta, Edmonton, AB, Canada.
Department of Anesthesia, University Hospital, London Health Sciences Centre, Windermere Road, London, ON, Canada.
Can J Anaesth. 2018 Feb;65(2):178-187. doi: 10.1007/s12630-017-1021-y. Epub 2017 Nov 21.
The anterior iliac crest (AIC) is one of the most common sites for harvesting autologous bone, but the associated postoperative pain can result in significant morbidity. Recently, the transmuscular quadratus lumborum block (TQL) has been described to anesthetize the thoraco-lumbar nerves. This study utilizes a combination of cadaveric models and clinical case studies to evaluate the dermatomal coverage and analgesic utility of TQL for AIC bone graft donor site analgesia.
Ten ultrasound-guided TQL injections were performed in five cadaver specimens using a lateral-to-medial transmuscular approach. Twenty mL of 0.5% methylcellulose was injected on each side after ultrasound confirmation of the needle tip ventral to the quadratus lumborum muscle (QLM). Cranio-caudal and medial-lateral extent of the dye spread in relation to musculoskeletal anatomy and direct staining of the thoraco-lumbar nerves were recorded. Following the anatomical findings, continuous catheter TQL blocks were performed in four patients undergoing ankle surgery with autologous AIC bone graft. The dermatomal anesthesia and postoperative analgesic consumption were recorded.
In the anatomical component of the study, 9/10 specimens showed a lateral spread anterior to the transversalis fascia and medially between the QLM and psoas major muscle. Direct staining of the branches of the T12, L1, and L2 nerves was noted ventral to the QLM, while variable staining of the T9-T11 nerves was seen laterally in the transversus abdominis plane and the transversalis fascia. The vertical spread of injectate anterior to the QLM was T12 to the iliac crest (n = 5/10) and L1 to the iliac crest (n = 4/10). In the four patients who received TQL, the T9-L2 dermatomal anesthesia correlated with the injectate spread seen in the cadavers and provided effective analgesia at the bone graft donor site.
Ultrasound-guided TQL injections consistently cover the thoraco-lumbar innervation relevant to the AIC graft donor site. The injectate spread seen in anatomical dissections correlated with the dermatomal anesthesia clinically. The TQL has the potential to provide reliable analgesia for patients undergoing AIC bone graft harvesting.
髂前嵴（AIC）是自体骨采集最常用的部位之一，但相关的术后疼痛会导致明显的发病率。最近，经肌四头肌方肌阻滞（TQL）已被描述用于胸腰椎神经麻醉。本研究结合尸体模型和临床病例研究，评估 TQL 用于 AIC 骨移植物供区镇痛的皮节覆盖范围和镇痛效果。
在五个尸体标本中，采用外侧到内侧经肌 TQL 注射法进行了 10 次超声引导 TQL 注射。在超声确认针尖位于腰方肌（QLM）腹侧后，在每侧注射 20ml 0.5%甲基纤维素。记录染料扩散的头尾方向和内外方向与肌肉骨骼解剖结构的关系，以及胸腰椎神经的直接染色。在解剖学发现之后，对 4 例接受自体 AIC 骨移植物踝关节手术的患者进行连续 TQL 导管阻滞。记录皮节麻醉和术后镇痛消耗。
在研究的解剖部分，9/10 个标本显示横突筋膜前外侧和 QLM 与腰大肌之间的内侧扩散。QLM 腹侧可见 T12、L1 和 L2 神经分支的直接染色，而 T9-T11 神经的可变染色则见于腹横肌平面和横突筋膜的外侧。QLM 前的注射剂垂直扩散范围为 T12 至髂嵴（n=5/10）和 L1 至髂嵴（n=4/10）。在接受 TQL 的 4 例患者中，T9-L2 皮节麻醉与尸体中所见的注射剂扩散范围相关，并在骨移植物供区提供有效镇痛。
超声引导 TQL 注射可始终覆盖与 AIC 移植物供区相关的胸腰椎神经支配。解剖学解剖中所见的注射剂扩散范围与临床皮节麻醉相关。TQL 有可能为接受 AIC 骨移植物采集的患者提供可靠的镇痛效果。
